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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603496
Report Date: 12/13/2021
Date Signed: 12/13/2021 11:20:16 PM

Document Has Been Signed on 12/13/2021 11:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:PACIFIC BREEZEFACILITY NUMBER:
374603496
ADMINISTRATOR:PHOMTHAVONG, KEVINFACILITY TYPE:
740
ADDRESS:137 PLAYA DEL REY AVETELEPHONE:
(760) 453-2722
CITY:OCEANSIDESTATE: CAZIP CODE:
92058
CAPACITY: 6CENSUS: 6DATE:
12/13/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Licensee, Monica SiharathTIME COMPLETED:
03:02 PM
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Licensing Program Analyst, (LPA), Kristina Ryan conducted an unannounced Case Management - Legal/Non-Compliance visit. The purpose of the visit was to conduct an inspection to ensure ongoing compliance with regulations and laws and ensure the health and safety of residents in care. LPA was granted entry by Caregiver, Reymundo Garvida, and met with Licensee, Monica Siharath. LPA was granted entry after identifying herself and disclosing the purpose of the visit.

During today’s visit, LPA toured the facility, observed residents in care, and provided consultation regarding Title 22 requirements. LPA discussed most recent COVID-19 guidance and reviewed the facility’s mitigation strategies.

Based on today’s inspection, there were no deficiencies cited at this time in the areas evaluated. An exit interview was conducted with Ms. Siharath. A copy of this report and Licensee's Appeal Rights (LIC 9058 01/16) were provided to the Licensee via e-mail. A confirmation receipt has been requested.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Kristina Ryan
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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